VISION BENEFITS
Your vision and eye care is an important part of your overall health. Our National Vision Administrators( NVA) Vision Plan gives you access to a large network of providers for high quality, affordable care.
The plan makes it easy for you and your covered dependents to have an annual eye exam for only a $ 10 copay using NVA’ s extensive network of retail and independent providers. The plan also covers eyeglasses( frame and lenses) or contacts each year.
PLAN FEATURE PARTICIPATING PROVIDER NON-PARTICIPATING PROVIDER
Examination( once every calendar year) 100 % after $ 10 copay Up to $ 45
Lenses( once every calendar year) Single Vision Bifocal Trifocal Lenticular Progressives – Tier 1 Progressives – Tier 2 Progressives – Tier 3 Progressives – Tier 4 Progressives – Tier 5 Progressives – Tier 6 Progressives – Tier 7
100 % after $ 10 copay 100 % after $ 10 copay 100 % after $ 10 copay 100 % after $ 10 copay 100 % 100 % 100 % 100 % $ 30 copay $ 55 copay $ 80 copay
Up to $ 30 Up to $ 45 Up to $ 55 Up to $ 90 Up to $ 50 Up to $ 80 Up to $ 100 Up to $ 120 Up to $ 140 Up to $ 165 Up to $ 190
Frames( once every calendar year) Retail allowance up to $ 150( 20 % discount off balance)*
Up to $ 70
Contact Lenses( once every calendar year) In lieu of eyeglasses In lieu of eyeglasses
Elective Contact Lenses
Up to $ 150 Retail( 15 % discount for conventional or 10 % discount for disposable)**
Up to $ 120
Fit / Follow-Up *** Standard Daily Wear Standard Extended Wear Specialty Wear
100 % after $ 10 copay 100 % after $ 10 copay 100 % after $ 10 copay
Up to $ 20 Up to $ 30 Up to $ 50
Medically Necessary **** 100 % Up to $ 210
* Does not apply to Costco, Wal-Mart / Sam’ s Club or Lenscrafters locations or for certain proprietary brands. ** Does not apply to Costco, Wal-Mart / Sam’ s Club, Lenscrafters, Contact Fill( NVA Mail Order) or certain locations at: Target, Sears, Pearle, & K-Mart and may be prohibited by some manufacturers. *** Only covered if you choose Contact Lenses. **** Pre-approval from NVA required.
2025 BENEFITS DECISION GUIDE | 9